The Rules of Verbal Jiu-Jitsu With Patients: how to deflect and defuse manipulative conversations

You are seeing a newly booked
patient in your jail medical clinic. He states that the last time he was in
jail, he was given a second mattress because he had surgery on his back many
years ago. You note that the patient has not seen a doctor on the outside for
many years, that the patient walks and moves normally, and that he has a normal
neurological examination. You tell the patient that medical does not give out
passes for extra mattresses. The patient angrily erupts in a blaze of
obscenities and threatens a lawsuit.

Manipulation happens when a patient
wants something that they should not have (like an extra mattress and pillow)
and will not accept “NO” for an answer. There are several strategies
patients may employ in an attempt to force practitioners to change a
“No” to a “Yes.” This patient started with the “other
doctors gave me what I want” strategy and when that didn’t work, he
employed the “threatening” strategy. (I covered this in more detail in a post last month.)

Verbal Jiu-Jitsu is what I call the
technique of deflecting and defusing such manipulative confrontations. The
first and most important rule of Verbal Jiu-Jitsu is to remember that this is
not a war or a contest! There should be no “battle of wills” between
you and your patient. There is no winner or loser. Instead, you and your
patient are having a conversation. The whole goal of Verbal Jiu-Jitsu is to
avoid any kind of verbal battle.

I know that it is tempting to think
of an unpleasant verbal exchange as a debate-style contest, with a winner and a
loser at the end. But even if you “win” a verbal battle, you’ve
actually really lost because you have not accomplished your goal of getting
your patient to understand and accept your treatment plan! Your patient is
still not happy and will simply renew the verbal battle at another time in
another way — and maybe more effectively next time.

The second rule of Verbal Jiu-Jitsu
is to have compassionate understanding of your patient. That person in front of
you is not an opponent to be defeated. He is your patient. Like everybody else,
inmates are just trying to get by as well as they can in a very tough
environment — they’re in jail! It’s just that many inmates (and people on the
outside, for that matter) have poor interpersonal skills and resort to
pathological social habits. This is what they know and what works for them. If
a patient has successfully gotten his way throughout his life by bullying and
threatening others, that is how he is going to interact with you, too.

You don’t have control over this —
but you do have control over your reaction. When patients confront you with
threats, they will expect you to respond the way that most other people would
— which is either to fight back or to give in. You should do neither.

Take, for example, the case of this
patient in your clinic who has angrily threatened to sue you plus has lobbed in
a few F-bombs for good measure. There he is, red faced, fists clenched, and
LOUD. Nurses, deputies, and other inmates are watching. How are you going to
handle this? How will you accomplish your goal of defusing the situation and
facilitating reasonable communication with your patient?

The single worst thing you could do
would be to respond to anger with anger: “You can’t talk to me like that!
Get the hell out! Who do you think you are?” First of all, the patient is
accustomed to this type of response and will be far more comfortable and
effective with a loud confrontation than you.

Second, the patient (and everyone
watching) have now learned that a verbal confrontation is an effective way of
getting under your skin — very useful information! Also, since you (hopefully)
are not practiced and adept at angry shouting, your heart will be jack-hammering
and you’ll develop a monster headache — at least that’s what would happen with
me. You will have ruined your own mood for the rest of the day. How effective
are you then going to be with the rest of your clinic schedule?

Finally, the fight is not over! The
patient can (and will) renew the attack at another time.

Another wrong response is to
compromise: “There is no reason to be angry! Calm down and we can work
something out.” This is a mistake! If you compromise, you have established
the precedent that becoming angry is an effective strategy with you. Other
inmates will learn this and you will inevitably have to endure many more
confrontations like this.

Instead, defuse and deflect. One way
would be to say: “I see that you are angry, so we are done for now.
Security will take you back to your dorm. We’ll talk again later after you’ve
calmed down.” It’s important to say this without raising your voice and,
if possible, to betray no emotion on your face or body language. The lack of
any reaction goes a long way to defusing such situations. No compromise, no
bargaining, no reaction.

The next day — or even in an hour
or two — you can call the patient back to medical and confidently expect a
more productive conversation. It is important at this second interaction not to
upbraid or belittle the patient. You should act as if the last incident is
forgotten.

It takes training, practice, and
time to master verbal defense skills. The best way to learn is through
role-playing scenarios. The response to angry outbursts happens to be one of
the easiest Verbal Jiu-Jitsu skills to learn. The principles are: betray no
reaction or emotion, end the session (if the patient will not calm down
immediately), but make sure that such patients know that they are welcome back
as soon as they calm down. Bring them back later and act as if the incident is
forgotten.

Jeffrey E. Keller, MD, FACEP, is a board-certified emergency physician with 25 years of experience before moving full time into his “true calling” of correctional medicine. He now works exclusively in jails and prisons, and blogs about correctional medicine at JailMedicine.com.